Fee-for-service limits long-term work on social determinants, execs warn

Retooling insurance coverage to help address issues outside of direct clinical care could lead to savings for the healthcare system.

Dr. Adam Myers
Chief population health officer
Cleveland Clinic

CLEVELAND—Health system leaders have embraced their role in addressing patients’ social needs but argue that it’s unsustainable long term under the current payment system.

While executives from across the industry shared ongoing efforts to tackle issues that plague their communities during Modern Healthcare’s Critical Connections: Social Determinants of Health Symposium in Cleveland on June 6, they wondered how deep of an impact can be made if reimbursement doesn’t soon follow.

Addressing patients’ social needs is “economically unsustainable in a fee-for-service world,” said Dr. Lawrence Moss, CEO of Nemours Children’s Health System based in Jacksonville, Fla. “You can do these things and they work, but you need an economic model that supports them if we are going to scale them up to a nationwide effort.”

Nemours has for several years worked on addressing the social needs that cause patients to show up in the emergency room for asthma. In some cases it involves visiting the patient’s home to understand what’s triggering an attack. The efforts have led to a 50% reduction in ER visits and readmissions for asthmatic patients. Although the benefits of the program are great for children, it’s “also a cost to the health system” because fewer patients are using their services, Moss said.

Additionally, health systems are limited to doing much beyond clinical care, said Dr. Adam Myers, chief population health officer at the Cleveland Clinic.

Myers discussed the struggle he faced while working in Texas to help provide a home air conditioning unit for a chronic obstructive pulmonary disease patient. Heat would exacerbate the patient’s COPD symptoms, but his insurance carrier wouldn’t cover the expense of an A/C unit. Myers said figuring out how to retool insurance to cover such things will lead to savings for the healthcare system.

The CMS is considering such an idea. Late last year, HHS Secretary Alex Azar said the agency is putting together a pilot that would allow healthcare organizations to bill the CMS for providing such social services as assistance with food and housing.

Randy Oostra, CEO of ProMedica, also suggested that the CMS should require hospitals to screen all patients for social needs as part of Medicare payment. “We would connect the clinical to the social aspects and overnight you will see this huge change in American hospitals,” Oostra said.

The continued transition to value-based payment will support the focus on social risk factors as well, said Dr. Dan Simon, president of University Hospitals Cleveland Medical Center.

While fee-for-service payment gives providers incentives to do more for patients, value-based care would focus on keeping patients out of doctor’s offices, thus encouraging providers to focus on social issues that exacerbate or cause health problems.

“When you start thinking about value, the social determinants fall right in,” Simon said.

Even though providers agree they have an obligation to address patient social needs, they also recognize they can’t solve these problems on their own.

Nemours partnered with community groups when the asthma prevention program began, including the Delaware Division of Public Health. “We can’t go in a room and make this up by ourselves as a health system,” Moss said. “We know medical care. We don’t know social services, so we need partners. Our role was a convener to bring the experts to the table, not act as the self-appointed expert.”

In addition to partnering with the community, health systems have an obligation to advocate for policy changes that would have widespread effects on the social determinants of health impacting their communities, said Brian Castrucci, CEO of the not-for-profit de Beaumont Foundation, which focuses on improving community health.

When health systems create programs that address social needs on a patient-by-patient basis, that’s only helping the patient and their specific challenges. It’s also not fixing the cause of the problem, he said. As anchors in their community, healthcare organizations should approach senators and local councilmen to enact policies that have a real impact on health.

“You guys come in, and they view it differently. You need to use the power of your position to get the solutions we need,” Castrucci said.